Adverse Childhood Experiences in Trainees and Physicians With Professionalism Lapses: Implications for Medical Education and Remediation

Abstract

It is now well accepted that unprofessional behavior by practicing physicians can have a negative impact on patient safety and quality of care. [1][2][3] Further, unprofessional behavior during training is associated with unprofessional behavior in later practice and regulatory involvement. 4-6 Such behaviors can be classified into the following broad categories: failure to engage, dishonest and/or disrespectful behavior, and poor self-awareness. Specific behavioral examples include poor collaboration, failure to incorporate feedback, argumentative communication, poor teamwork, externalizing blame, and failing to establish and maintain appropriate boundaries. 7In our clinical experience, these behaviors are somewhat consistent with behaviors that are often demonstrated by those with a history of adverse childhood experiences (ACEs). ACEs can include actual and/ or vicarious exposure to physical or sexual abuse, neglect, or loss of a parent. Exposure to such experiences has a strong positive correlation with medical and mental health issues in adult life, [8][9][10][11][12] and there appears to be a dose-response (or exposure-response) relationship between the number of ACEs a person experiences and subsequent medical and mental health difficulties. 10,11 Additionally, developmental exposure to trauma appears to predispose individuals to problems in responding appropriately to subsequent trauma, as they may become self-protective, exert excessive energy scanning their environment for threats, and experience ongoing low levels of fear and heightened vigilance, which can contribute to decreased curiosity, exploration, and learning. 12 Other difficulties associated with exposure to ACEs include affect dysregulation, difficulties labeling and expressing feelings and internal states, difficulties with self-concept, lack of continuous and predictable sense of self, low self-esteem, and experiencing feelings of shame and guilt. 13 Exposure to ACEs may also contribute to a person's decision to choose a helping profession. [14][15][16][17][18] However, there is a small but developing literature suggesting a relationship between boundary issues or sexual misconduct and attachment issues in physicians. 19,20 Sequelae of ACEs in medical trainees and physicians may manifest as professionalism lapses and difficulties with practice-based learning and improvement, such as defensiveness, shame, mistrust, difficulty with collaboration, and heightened reactivity, which may restrict receptivity to feedback, impair learning, and play a potential role in the manifestation

Prevalence of adverse childhood experiences and associations with personal and professional factors in health and social care workers: A systematic review.

“…Studies differed in their approach to gathering data, using online questionnaires ( n = 11), surveys ( n = 5), and those referred for fitness for duty evaluations ( n = 1). Only one study used retrospective data (Williams et al, 2021).…”

“…MERCER, COOKSON, SIMPSON-ADKINS, AND VAN VUUREN welfare professionals (n = 3), physicians (n = 3), social workers (n = 2), mental health providers (n = 2), nurses (n = 1), workers in a residential setting (n = 1), direct support professionals in learning disability settings (n = 1), medical healthcare professionals (n = 1), professionals (majority health and social services; n = 1), home visitors (n = 1), and emergency medical services personnel (n = 1). In their sampling, some studies included amalgamated data from both direct and indirect workers (Esaki & Larkin, 2013;Howard et al, 2015Howard et al, , 2017Lee et al, 2017) and one sample included combined data from those in training, as well as qualified, physicians (Williams et al, 2021). The samples in Ford et al (2021) were professionals from a range of backgrounds, with a majority from health and social services.…”

Post graduate remediation programs in medicine: a scoping review

“…Personal factors contributing to the need for remediation include: mental health concerns including anxiety, depression and stress [ 6 , 11 , 65 , 66 , 71 , 74 , 85 , 93 – 102 ], poor physical health [ 74 , 97 , 99 ] learning disability or difficulties (e.g. conceptualisation, time management or assessment anxiety) [ 6 , 65 , 85 , 93 , 96 , 98 , 100 , 102 – 104 ] substance abuse [ 65 , 66 , 68 , 85 , 93 , 99 , 105 , 106 ] personality disorders [ 88 , 95 ] personal relationship concerns such as divorce [ 65 , 66 , 74 , 94 , 101 ] lack of resilience, and setbacks that threaten one’s identity [ 92 , 106 ] …”

An investigation of preceptors' perceptions of behavioral elements of “professionalism” among genetic counseling students

“…The facets of professional behavior for which participants reported a high degree of lapses among genetic counseling students included self‐awareness, time management, and thoroughness, all in the behavioral domain of accountability and conscientiousness. Self‐awareness is considered to be an important category of professional behavior in medical education (Williams et al, 2021), although a lack of self‐awareness was the least common (9.8%) lapse identified in a sample of medical students from the United States and Canada (Ziring et al, 2015). However, aspects of time management such as tardiness and missed deadlines were the most common professional lapses reported in the same sample of medical students (Ziring et al, 2015).…”